5.2.8 Risk assessment

5.2.8 Risk assessment

Understanding the Principles of Risk Assessment

  • A patient’s narrative regarding their own personal risk should be included in the assessment.
  • Consent to risk assessment should be obtained, and the risks and benefits should be explained.
  • Preparation is essential, and physicians should seek information from as many credible sources as possible.
  • Involving the patient and caregivers (where appropriate) in the planning process can improve safety.
  • The contact between the doctor and the patient is critical; positive relationships make assessment simpler and more accurate, and they may lower risk.
  • All physicians should take detailed, inquisitive, and comprehensive histories.
  • It may be difficult for a single clinician to conduct an appropriate risk assessment. Discussing evaluations and management strategies with a colleague or supervisor is always beneficial.

Risk Assessment should always attempt to consider past/present behaviours, and also any protective factors. 

Often your hospital trust will use a standardised form of risk assessment. There are 85 mental health trusts in the UK, thus a lot of different forms.

Some points to consider:

  • Self-harm
  • Suicide
  • Alcohol
  • Illicit substances
  • Driving
  • Any children involved
  • Self-neglect
  • Harm to others
  • Violence and aggression
  • Exploitation by others
  • Physical health
  • Falls
  • Absconding

Factors to Consider

History:

  • Previous risk, whether investigated, mitigated for, or managed.
  • Associations to mental state and risk.
  • Absence of supporting relationships.
  • Poor treatment adherence, discontinuance, or disengagement.
  • Impulsivity
  • Alcohol and illicit substance misuse.
  • Being exposed to varying types of risk at a young age
  • Are the risk variables steady, or have they lately changed?
  • Is there anything that could affect the risk?
  • Recent stresses, losses, or the fear of loss.
  • Factors that have previously prevented the person from responding in a risky manner.
  • Are the family/caregivers at risk?
  • Empathy impairment.
  • The relationship between risk and personality traits.

Environment:

  • Risk factors may differ depending on the setting and the patient population.
  • Think about protective factors or the loss of protective factors.
  • Reduced bed capacity and the risks or alternatives to admission.

Working Knowledge of at Least One Recognised Risk Assessment  Tool Used to Assess Risk

There is an ever-increasing number of risk assessment tools and clinical algorithms in many areas of science and medicine. Risk assessment integrates psychological and social aspects as part of a thorough review to identify patient care requirements and estimate their risk of harm to themselves or others. Assessments frequently try to classify patients as high, medium, or low risk. Checklists or risk assessment tools are sometimes used for risk assessment, although evidence indicates that they are ineffective in predicting suicide.

NICE guidelines on the long-term management of self-harm state that risk assessment tools should “not be used to predict future suicide or repetition of self-harm, or to determine who should or should not be offered treatment”. The guidelines suggest they might be used as prompts or measures of change17.

A national confidential inquiry into suicide and safety in mental health was carried out in 2018: The assessment of clinical risk in mental health services National Confidential Inquiry into Suicide and Safety in Mental Health. The take-home messages can be seen below:

References:

(1) The assessment of clinical risk in mental health services National Confidential Inquiry into Suicide and Safety in Mental Health. (2018). [online] Available at: https://www.research.manchester.ac.uk/portal/files/77517990/REPORT_The_assessment_of_clinical_risk_in_mental_health_services.pdf.

(2) RCPSYCH ROYAL COLLEGE OF PSYCHIATRISTS. (n.d.). Assessing risk. [online] Available at: https://www.rcpsych.ac.uk/members/supporting-your-professional-development/assessing-and-managing-risk-of-patients-causing-harm/assessing-risk.

(3) National Institute for Health and Care Excellence (NICE). Self-harm in over 8s: long-term management. Clinical guideline. London: NICE, 2011. https://www.nice.org.uk/guidance/cg133/resources/selfharm-in-over-8slongterm-management-pdf-35109508689349